Death and End-of-Life Care in Emergency Departments in the US

Abstract

ImportanceThere are more than 140 million annual visits to emergency departments (EDs) in the US. The role of EDs in providing care at or near the end of life is not well characterized.ObjectiveTo determine the frequency of death in the ED or within 1 month of an ED visit in an all-age, all-payer national database.Design, Setting, and ParticipantsThe retrospective cohort study used patient-level data from the nationally representative Optum clinical electronic health record data set for 2010 to 2020. Data were analyzed from January to March 2022.ExposuresAge, Charlson Comorbidity Index (CCI), and year of ED encounter.Main Outcomes and MeasuresThe primary outcome was death in the ED, overall and stratified by age, CCI, or year. A key secondary outcome was death within 1 month of an ED encounter. We extrapolated to make national estimates using US Census and Nationwide Emergency Department Sample data.ResultsAmong a total of 104 113 518 individual patients with 96 239 939 ED encounters, 205 372 ED deaths were identified in Optum, for whom median (IQR) age was 72 (53 to >80) years, 114 582 (55.8%) were male, and 152 672 (74.3%) were White. ED death affected 0.20% of overall patients and accounted for 0.21% of ED encounters. An additional 603 273 patients died within 1 month of an ED encounter. Extrapolated nationally, ED deaths accounted for 11.3% of total deaths from 2010 to 2019, and 33.2% of all decedents nationally visited the ED within 1 month of their death. The proportion of total national deaths occurring in the ED decreased by 0.27% annually (P for trend = .003) but the proportion who died within 1 month of an ED visit increased by 1.2% annually (P for trend < .001). Compared with all ED encounters, patients with visits resulting in death were older, more likely to be White, male, and not Hispanic, and had higher CCI. Among ED encounters for patients aged older than 80 years, nearly 1 in 12 died within 1 month.Conclusions and RelevanceThis retrospective cohort study found deaths during or shortly after ED care were common, especially among patients who are older and with chronic comorbidities. EDs must identify patients for whom end-of-life care is necessary or preferred and be equipped to deliver this care excellently.

Impact of First Wave of COVID-19 Pandemic on Mortality at Emergency Department in Older Patients with COVID and Non-COVID Diagnoses

“…We find that ED mortality at the onset of the first pandemic wave at least doubled in non-COVID older patients and tripled in COVID older patients compared to pre-pandemic older patients seen in the same EDs. This mortality is higher than that found in other studies prior to the pandemic [4,5].…”

“…Among these outcomes, death accounted while patient is being attended in the ED (ED mortality) is one of them, and it is one of ED quality marker most frequently used. The ED mortality affected 0.20-0.30% of overall patients and was most common among patients who are older and with chronic comorbidities [4,5]. In many cases, they are older patients with trauma or at the end of life.…”

Ransomware Cyberattack Associated With Cardiac Arrest Incidence and Outcomes at Untargeted, Adjacent Hospitals

“…To our knowledge, this is the first report of the association of CA incidence and outcomes at a neighboring hospital system adjacent to a ransomware-infected HDO. The increase in CAs mirrored the increase in strokes previously reported during the same time period (5). Additionally, we analyzed the 4-year period before the ransomware cyberattack using an ARIMA model to account for seasonal and secular variation.…”

“…This hypothesis is consistent with prior studies that found events resulting in increased EMS diversions, such as marathons, are associated with longer ambulance transport times and higher 30-day mortality (10). Although increased EMS diversion time has been previously reported related to this event (5), we do not have complete data regarding EMS transport times to determine if diversions were relevant to our specific CA cases.…”

“…Although the operational effects of ransomware-infected HDOs have been reported, there are limited data regarding how ransomware cyberattacks impact adjacent, untargeted hospitals (4). To our knowledge, Dameff et al (5) was the first study patient outcomes in neighboring, untargeted hospitals and found Ransomware Cyberattack Associated With Cardiac Arrest Incidence and Outcomes at Untargeted, Adjacent Hospitals increases in strokes during the cyberattack month, demonstrating the ripple effects of cybersecurity disruption. In addition to stroke victims, patients with other time-sensitive, resource-intensive conditions including out-of-hospital cardiac arrests (OHCAs) were diverted from the ransomware-infected HDO to other hospitals (6).…”